NIHD WHEN LEAN MEETS EBD Terri Zborowsky, PhD 05.18.2017 Terri - - PowerPoint PPT Presentation

NIHD WHEN LEAN MEETS EBD

Terri Zborowsky, PhD 05.18.2017

Terri Zborowsky, PhD, EDAC

5/18/2017 2

 Nursing Certificate (RN)  BID, MSc, PhD Interior Design  Experience 20+ years (Interior Designer, Medical Planner, Medical Equipment Planner,

Director of E&R at Ellerbe Becket)

 3 years Research Associate at CHD  Design Researcher, HGA  Adjunct Instructor, Center for Spirituality & Healing & School of Nursing, U of MN  Member, Nursing Institute for Healthcare Design (NIHD)  Advisory Board Member, HERD Journal

Agenda

• Evidence based Design/

Practice based Research

• Lean
• Case Studies
• Q&A

The Problem—the same one…

Healthcare Problems

Plesak, P. (2003). Complexity and the Adoption of Innovation in Healthcare.

Simple Problem Complicated Problem Complex Problem

7

HGA Case Study

LEAN EBD Pre-Design DISCOVER Schematic APPLY Development TEST/PREDICT Documentation VERIFY Post-Occupancy COMPARE

Patient Experience Big Questions Critical to Quality Current-State Evaluation Future-State Operational Models Rapid Prototyping Adjacencies Strategic Space Program Gather Baseline/ Current-State Data through Valid Methods Set Optional Standards & Goals Special Project Support (if necessary) Metrics Evaluation Performance Report Gather Baseline/ Current-State Data through Valid Methods Use Baseline Data to Develop Future-State Methods, Prototypes, & Program Test & Calculate Advantages of Future-State Models with Baseline Data; Aid in Decision Making Hypothesize Outcomes Verify Application of Evidence Collect Data Using Same Pre-Design Methods; Compare Data Sets & Test Hypotheses

Merging Methods: Lean & EBD

PROCESS IMPROVEMENT DATA GATHERING

Practice based Research

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Freihoefer, K. & Zborowsky, T. (2016). Making the Case for Practice-Based Research and the Imperative Role of Design Practitioners. HERD, XX, XX-XX.

HGA Research Toolkit

9

Designing RHCSF: An EBD Approach HGA Case Study

Pre-Design DISCOVER Schematic APPLY Development TEST/PREDICT Documentation VERIFY Post-Occupancy COMPARE

Shadowing Users Staff Survey: Questionnaires or Focus Groups Retrospective Data Collection Patient/Family Survey: Questionnaires or Focus Groups Shadowing Users Staff Survey: Questionnaires or Focus Groups Retrospective Data Collection Patient/Family Survey: Questionnaires or Focus Groups Critical to Quality Needs Impact of Design

“Critical needs are identified…to produce a Quality outcome”

Case Study #1

Nurses’ Station Med Supply/ Clean Soiled Nursery Entry

Office Office

Charting Charting Charting Charting WOW Alcove

Nourish Wait Office Edu

PROGRAM

• 11 Postpartum Rooms
• 4 Antepartum Rooms
• 18 Level II NICU Beds
• Newborn Nursery
• Lactation Teaching Rm

Shadowing Users Staff Satisfaction Questionnaires Retrospective Data Collection (HCAPHS)

• St. Elizabeth’s Hospital, Ministry Health Care

Post-Partum Unit Build-out, 2012

Shadow Tool

Go to GEMBA (Data Collection)

Nurse Server Central Nurse Station Rounding in Corridor Patient Room Patient View Staff View

HGA Benchmark Database

Triangular Unit A (1NS:10PR) Rural/Pods Unit B (1:9) Pass-Through Unit C (1:2) Supply Core Unit D (1:1) Academic Unit E (1:1) Patient Rooms 41% 52% 49% 54% 45% Charting Stations 37% 40% 34% 30% 41% Medication & Supply Rooms 7%

included in NS

5% 6% 4% Support Rooms 5% 1% 3% 5% 3% Corridor Traveling 9% 6% 10% 5% 7% Distance Traveled 2.53 miles 2.29 miles 2.44 miles 1.71 miles 1.87 miles

Generate Evaluations and Predictions to Inform Design Less time in nurses’ stations and traveling = more time in patient rooms. For 5 dayshift nurses, overall time saved traveling is approx. 2 to 4 hrs. Existing Unit Current State Benchmark Decentralized Studies Decentralized Prototype Prediction Patient Rooms 39% 45-54% +10-15% Charting Stations 43% 32-39%

• 4-8%

Medication & Supply Rooms 5% 1-5%

• 0-3%

Support Rooms 1% 2-5%

• 0-2%

Traveling 13% 5-8%

• 4-8%

Predictive Analyses

Prototype Testing: 2-hr shadow of RN rounding

.5 miles; ≈15.25 min.

• f travel

Existing Unit: Current State

.23 miles; ≈7.5 min.

• f travel

56% decrease

28 Bed-Option Unit: Future State

went to med room 7 times & nourishment 3 times for ice/water/food staff restroom busy, goes to another off the unit

LEAN – CTQ Evaluation EBD – Mock-Up Simulations

• St. Elizabeth’s Hospital, Ministry Health Care

Post-Partum Unit Build-out, 2012

Patient Experience Toolkit

CTQ: Efficiency (Critical Needs)

NEED 1: Patient discharge needs to be more efficient NEED 2: Staff needs a place to chart NEED 3: Staff needs to communicate with others NEED 4: Staff needs working environment that supports their safety NEED 5: Staff needs to focus patient care at the bedside

• Need quick, stand-up charting locations
• Need sit down charting stations
• Need to be less congested and noisy

CTQ: Efficiency (Quality Metrics)

• Patient d/c time increases
• Time at charting station increases
• Communication with others increases
• Staff incidents decrease
• Time engaged patient care at the bedside

increases

Categorize Findings into Critical to Quality

3-Phased POE

3 Months 8 Months 12 Months

Frequency of Trips

» Sign. reduction overtime (p< 0.001)

Post- Occupancy @ 3-months Post- Occupancy @ 8-months Post- Occupancy @ 12-months Overall Average 2.89 miles 2.04 miles 1.64 miles 2.08 miles

Travel Distances

Staff Questionnaire Results

Enhances or Hinders ability to get the job done

 Statistically Significant difference between Nurses’ Station and other areas (p***)

p*** p*** p***

• St. Elizabeth’s Hospital, Ministry Health Care

Post-Partum Unit Build-out, 2012

HCAHPS/IP Results

Pre & Post Occupancy

• St. Elizabeth’s Hospital, Ministry Health Care

Post-Partum Unit Build-out, 2012

Correlations

Health & Well-being R=.47 Job Satisfaction R=.59 Work Performance R=.71 Servers

East Coast Hospital

Case Study #2

Shadowing Users Staff Satisfaction Questionnaires Staff Focus Group & Interviews

POE Process

Quick Post Occupancy Evaluation

2 hour Focus Group with Managers/Supervisors 18 Interviews with Front-line Staff 5 hours of Shadowing

• 1. Study current inpatient unit to inform

design decision of next project.

• 2. Uncover lessons learned from

inpatient unit--What works for front- line staff, what doesn’t.

• 3. Evaluate the CtQ needs identified for

the Hospital.

• 4. Provide report out summary ppt to

share with the design team.

Original IP Critical to Quality Needs

• 1. CHARTING
• 1 : 4 Ratio (Med/Surg)
• 1 : 2 Ratio (ICU/CCU)
• Option for private charting space

for ancillaries & MD's

• HIPAA Compliant
• Visualization from Charting to Rooms
• 2. VISUALIZATION
• Caregiver-to-caregiver visibility
• Visitor-to-caregiver visibility
• Visibility to Patient in room (casual)
• Visibility of multiple Patient Rooms across unit
• Patients don't feel isolated
• 3. COLLABORATION
• Space for collaboration outside room
• Limit noise from collaboration into Patient

Rooms

• 4. SUPPLIES
• In-Room Server for commonly

used supplies & linens

• Central location for less frequently used items
• 5. PORTABLE DIAGNOSTICS
• Central location for portables, easily accessible
• 6. PATIENT TRANSPORT
• Transport equipment on unit
• Elevator, door, corridor width to support transport
• 7. NUTRITION
• Storage area for food trays
• Family access to nourishment area
• 8. MEDICATIONS & PNEUMATIC TUBE
• Pyxis centrally located
• More than 1 P-Tube
• Narcotic storage (1:24) in central Med Room
• 9. STAFFING TO VARIABLE CENSUS
• Limit moving patients for staffing efficiency
• 10. REHAB THERAPY
• Area in room for Rehab therapy

Staff Questionnaire

24 beds/unit

REPORT OUT: INTERVIEWS

Report Out: Interviews

General Questions

• 1. Tell us what it is like to work at XXX?

Content Specific Questions

• 2. What design elements on the med/surg unit

supports or detracts from your work flow?

• 3. Do you have enough privacy (audio/visual)?
• 4. Can you find other staff (supplies/medications) when

you need to?

• 5. Where does collaboration happen?
• 6. What distracts you at work?
• 7. What do patient’s complain about the most?
• 8. Do you feel safe at work?
• 9. If you could change one design item on the unit,

what would it be? Wrap-up Question

• 10. What else would you like us to know?

Interviewed Nurses 2 Unit Technicians 1 EVS 3 Unit Secretary 2 Material’s Mgmt Technicians 2 IV Pump Manager 1 Lab Manager 1 Infection Control Nurse 1 Pharmacist 1 Pharmacy Technicians 2 Rehab (OT/PT) 2

Critical to Quality Needs Issue Design Process

• 1. Charting

Charting Stations No issue after adding 8 more stations, other than people seem to want to be in the Huddle space. Create more charting station

• pportunities in the Hub

spaces. Huddle Spaces Tables moved therefore pendant fixtures and floor

• utlet are a trip hazard.

Reconsider the design of the Huddle spaces. Huddle Spaces

• 2. Visualization

No issue…can see (4) patients from huddle space and see other staff. Family may not be able to see staff in the corridor but find them in the Huddle Spaces.

• 3. Collaboration

No issue…”more collaboration happens” because of the “Collaboration Hubs.” Noise/ Alarm fatigue Noise at the Huddle Space— alarms and voices. Nurse calls slow to respond Nurse call should roll over to another staff member if staff are busy with a patient.

Critical to Quality Needs Issue Design Process

• 4. Supplies

Nurse servers poorly stocked at times Supply chain breakdown— upsets JIT delivery system (chicken and the egg). Standardize contents and how Nurses use them (no hoarding) Nurse server locks a challenge Specify new lock mechanism Specialty Beds Stored at Gainesville, take time to arrive here. Seems to be true for other supplies as well.

• 5. Portable Diagnostics

No issues

• 6. Patient Transport

No issues

• 7. Nutrition

Dirty tray storage not working as intended. Redesign this area Are there any process changes needed with this fix?

Cast Room

Critical to Quality Needs Issue Design Process 8.1 Medications Medication Server access Accessing the med servers from one side (in patient room) creates stress for the patient and increases time for the Pharm Techs. . Medication Room Size One is smaller and harder to stock with IV fluids. Also difficult to fit more than 2 to 3 people at a time so Pharm Tech has to wait at times to access. 8.2 Pneumatic Tube Station (PTS) PTS access—tubes get backed up because staff work isn’t near the PTS. Add work surface next to PTS for unloading items. Can the PTS alarm to nurse phones to notify them when something arrives?

• 9. Staffing to variable census

No issue—the “step-down” unit flexes well between ICU and Med/Surg.

• 10. Rehab Therapy

Because of lack of Dept. space, RT has commandeered a coll. hub. End of hall, visitor furniture removed for patient steps. Incorporate steps into each unit (preferred).

Other Input Issue Design Process EVS No shelves in EVS closets for supplies. Some paper towel disp are mounted higher than others. Add shelves and standardize dispenser heights. Time to turn rooms around. Nurses need to strip rooms to save EVS time in room turn-

• ver.

They clean out sharps disposal at times. Vendor should do this. Equipment Cleaning Room Dirty and clean storage in same room. Redesign space to separate functions. Equipment (IV Pumps) IV pumps get ‘lost’ in the dirty rooms—sometimes hard to get at. . Conduct a S5 to tape off locations on the floor for the pumps so they can easily be found. Lab Access to their system on the units Can download their software to one computer on each unit? Dock Dock is overloaded with supplies JIT supply chain is broken. Wayfinding Wayfinding problems Add LDR to airport signage Keep doors to unit open unless unit in lock-down

Loading Dock

Other Input Issue Design Process Vending Services Provide more robust vending machines as café closes at night. Linen Supplies Need to store more linen on the units—others say it is

• fine. Recheck this.

Location for Patient Belongings (ED) No dedicated space for patient belongings Unit Secretary in the Knuckle Constant distractions (in greeter location), cramped

• n first floor.

Need at least a semi-private location. Also consider how EPIC may affect their tasks. RN Supervisor Access to hospital difficult from office location Would prefer office in the knuckle Staff Comfort Access to Staff toilet (issue is in ICU, M/S ok) Each unit should have a staff toilet Patient Comfort Thresholds between flooring material is a problem Reexamine this on the new floor. Visitor Bathrooms Directly across from knuckle, staff can hear. Reconsider door location on the new floor. Infection Control Concerns Curtains in patient room are potential infection control problem. Possible remove them (Infection Control preference)? Cleaning Issue—do not get cleaned if they are not visibly dirty

Other Input Issue Design Process Patient Room Issues Door handle issues—difficult to latch Review options with owner Retrieving supplies from a room without a door leaf can trap staff in a room—one or two doors only on the unit? Happens where there is a corridor door impacting space available. White board is brown & difficult for patient to see Consider another color—white markers are hard to find. Move whiteboard text closer to the corner. No place to set gait belt in clean zone Hook already added in Ortho unit Toilet paper location an issue for both EVS and patients Have all staff pull the grab bar down so pt can reach toilet paper Toilet Seat is low for Ortho patients Can anything be added to the height? Is this an OT item? Patient room recliner arm not removable, work around created for bed to chair transfer. Purchase recliners with removable arms for Ortho pt to assist with bed to chair transfers.

REPORT OUT: SHADOWING

Report out: Shadowing

Role and Responsibility Time Shadowed Nurse: Shift Change 45 min Nurse: Main Workflow 100 min Nurse: Room Turnover 10 min Technicians: Main Workflow 30 min Hospitalist: Main Workflow 45 min Rehab (OT/PT): Patient Bathroom 20 min Dietary: Receiving Orders & Meal Delivery 25 min EVS Shadowing 20 min Total 295 m / 4.9 hours

Time Spent By Position

Patient Room Collaboration Hub Collaboration Hub Corridor Patient Room Patient Room Patient Room Collaboration Hub Corridor Waiting / Family Consult Clean/Supplies/Linens Clean/Supplies/Linens

Time Spent By Room Type

Communication Collaboration Hub Medication Direct Patient Care Equipment / Supplies Interrupted Interrupted Communication Communication Direct Patient Care Direct Patient Care Equipment / Supplies

HUB What happens during this time?

Time Spent During RN Shift Change

 Tables in middle of areas cause

congestion and have been moved

 Available computers can be

challenging to find often resulting in sitting in the hallway, which is not preferred

 Quiet and uninterrupted space can

be challenging to find

 Lots of communication happens in

the hallway

HUBS AREAS & SHARED SPACES

Patient Care Communication

Equipment/ Supplies

Sanitize/PPE Charting

FEEDBACK

 Sharps container too small,

need to have two in the room

 Sharps not emptied properly

• r frequent enough

Patient Room

Time Spent During Technician Workflow

Stopped in Corridor Wait/Family Consult Medication Room Left the Unit

Time Spent During Hospitalist Workflow

PHYSICIAN FEEDBACK

 Can be challenging to find a

computer at times

 Quiet uninterrupted space on

unit can be difficult to find

Patient Room Collaboration Hub

 Total Distance Traveled

 160.94 ft (total time x min)

 Minimal transportation waste with current

layout

 Restocking of trays when delivering and

picking up food from patients can generate waste in motion

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Dietary

SUMMARY AND DESIGN ISSUES

Existing Med/Surg Family Waiting OB Family Waiting OB Patient Corridor

Existing Med/Surg Patient Room OB Patient Room OB Patient Room

Evidence-based Design and EDAC

 The Center for Health Design’s internationally recognized EDAC program awards credentials to

individuals who demonstrate a thorough understanding of how to apply an evidence-based design process to the design and development of healthcare settings, including measuring and reporting results.

 The EDAC exam establishes standards and tests individuals on the proper process to follow.  Use of the EDAC appellation distinguishes your knowledge and practice of EBD in healthcare.

Q&A